Optimizing Linkage and Retention to Hypertension Care in Rural Kenya. Cardiovascular disease (CVD) is the leading cause of death in sub-Saharan Africa among adults above age 30. The prevalence of hypertension, a major risk factor for CVD, is increasing over time in sub-Saharan Africa, exerting a significant epidemiologic and economic burden on the region. Without adequate control of hypertension, its health and economic burden will increase drastically in the decades ahead. Well established and evidence-based interventions to manage hypertension exist; however, treatment and control rates are low. A critical component of hypertension management is to facilitate sustained access of affected individuals to effective clinical services. In partnership with the Government of Kenya, the United States Agency for International Development-Academic Model Providing Access to Healthcare Partnership (AMPATH) is expanding its clinical scope of work in rural western Kenya to include hypertension and other chronic diseases. However, linking and retaining individuals with elevated blood pressure to the clinical care program has been difficult. Thus, the overall objective of this application is to utilize a multi-disciplinary implementation research approach t address the challenge of linking and retaining hypertensive individuals to a hypertension management program. Specifically, we propose to test the hypothesis that community health workers (CHWs), equipped with a tailored behavioral communication strategy and a smartphone-based tool linked to an electronic health record, can increase linkage and retention of hypertensive individuals to a hypertension care program and thereby significantly reduce blood pressure among these patients. We further hypothesize that these interventions will be cost-effective. Aim 1 is to identify facilitators and barriers to linking and retaining individualswith high blood pressure to a hypertension care delivery program, using innovative and novel qualitative research techniques. We will use the information derived from this investigation to design a tailored behavioral communication strategy and a smartphone-based tool to be used by CHWs to optimize linkage and retention of hypertensive patients. Aim 2 is to evaluate the effectiveness of CHWs equipped with these interventions in improving linkage and reducing blood pressure among hypertensive patients, by conducting a three-arm cluster randomized trial comparing: 1) usual care (CHWs with standard training on recruitment of individuals); 2) CHWs with an additional tailored behavioral communication strategy; and 3) CHWs with a tailored behavioral communication strategy who are also equipped with smartphones linked to the electronic health record. Aim 3 is to evaluate the incremental cost-effectiveness of each intervention arm of the cluster randomized trial, presented both in terms of costs per unit decrease in blood pressure and costs per reductions in CVD risk. The research will be accomplished by a multidisciplinary team of investigators with diverse and complementary expertise. We aim to add to existing knowledge on scalable and sustainable strategies for optimizing control of hypertension and other chronic diseases in low- and middle-income countries. RELEVANCE: Optimizing Linkage and Retention to Hypertension Care in Rural Kenya. Hypertension is the leading global risk factor for mortality and the global cost of suboptimal blood pressure is estimated to be nearly $1 trillion over the next decade. This project therefore aims to address a singularly critical health and development issue for low- and middle-income countries. The results of this work will add to the emerging body of knowledge on scalable and sustainable strategies for effectively managing hypertension and related chronic diseases in low- and middle-income countries, as well as resource-poor settings in the USA and other high-income countries.